Is It Possible to Shift Left in Surgery?
Bringing surgical teams closer to patients
How can surgery be safer and more efficient? By bringing the surgeon and the surgical team closer to the patient, earlier. Or “shifting left”.
Isn’t “shifting left” a tech thing?
“Shifting left” is a software development term coined in 2001. It means finding software mistakes early (thus “shifting left” in the timeline), before these mistakes become very costly.
On average, a mistake that costs $0 to fix in a planning phase, costs $80 to fix in development, $960 when found in testing, and $7600 to fix when found by customers
(you can read more about it here).
The fact that mistakes are more expensive to fix the later you are in a process is very intuitive. There are plenty of examples that have nothing to do with software (realizing that you don’t like yellow — cheaper in the store than after your puppy has been sleeping on that armchair for three weeks. I’m sure you can think of more).
How do software people shift left?
Software engineers have been working on shifting left for over two decades, and they have made incredible achievements. They use an approach called Agile and there are a few important aspects to it:
- More frequent iterations — instead of working for 3 months before getting any feedback, they work in smaller time units that allow incremental and continuous improvement.
- Structured interaction— instead of leaving it for everyone to decide how and when they interact, there’s a certain framework for communication. For example, there is a short daily meeting for teams, and periodical retrospective meetings that encourage learning from mistakes.
- Breaking silos — instead of encouraging communication between different stakeholders through heavy documentation, they encourage open communication channels (for example face to face conversations, or tools like Slack, that emerged because face to face is not always possible or easy enough)
- Less finger pointing — instead of trying to figure out who to blame for mistakes, they focus on learning from mistakes and trying to improve. It doesn’t mean people are not accountable for their mistakes — but it does mean mistakes are expected to happen, and creating an environment that supports learning from mistakes is critical.
Supported by a technology ecosystem that continuously evolves to make it easier to adopt these practices, the tech world has achieved efficiency and productivity that was unimaginable before Agile.
Does shift left make sense in surgery?
I find some similarities between software development and surgery. In both worlds teams consist of stakeholders in different roles that together try to get a job done. They work in a technology-driven environment that keeps getting faster and more complex. They have little time to coordinate, but the results of their work can be dramatically influenced by their level of collaboration.
One thing is clear: surgical mistakes are much more expensive than software mistakes, and this on its own is a reason to think about it.
There’s the aspect of surgical safety and patients’ lives. For example, the earlier the surgical team is aware of a patient’s allergies or existing conditions the more likely it is they avoid critical mistakes.
Shifting left and making the entire team aware of relevant information prior to starting the surgery can save lives. Atul Gawande’s famous surgical checklist study, published in 2009 in NEJM, showed that the slightest shift-left (a short list of critical items reviewed minutes before the procedure) can deliver striking results in terms of complications, infections and even death in surgery. The surgical safety checklist, also known as Time Out, is widely adopted in the surgical world today.
There is also an efficiency aspect: mistakes cost in time of highly trained human resources, expensive operating rooms (an operating room minute could cost $100), sophisticated equipment and supplies. Earlier knowledge of the surgical plan can significantly impact efficiency. A 2020 research from Michigan State University and Rutgers University found that a hospital could save on average $1,800 per surgery, or nearly $28 million annually for that hospital, by avoiding and reducing unplanned costs.
I believe there is a huge promise in adopting shift left and Agile principals in order to drive safety and efficiency in surgery.